Thyroid Pathology Quiz

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Question 1

A 28-year-old man presents to his GP with a 4cm mobile anterior neck mass. A fine needle aspirate is performed which reveals cells with ‘orphan Annie eye’ nuclei and psammoma bodies.

What is the most likely diagnosis?

A	Thyroglossal duct cyst
B	Follicular carcinoma
C	Medullary carcinoma
D	Papillary carcinoma
E	Lingual thyroid

Question 1 Explanation:

‘Orphan Annie eye’ nuclei are pathognomonic for papillary carcinoma. Although clinically a thyroglossal duct cyst is likely, the histology findings indicate papillary carcinoma. (Ref: Cotrans, Pathoma)

Question 2

What is the most common type of thyroid carcinoma?

A	Follicular carcinoma
B	Papillary carcinoma
C	Medullary carcinoma
D	Anaplastic carcinoma

Question 2 Explanation:

Papillary carcinoma is the most common type with ~80% of thyroid cancers being papillary. Follicular accounts for ~10%. Medullary accounts for ~5%. Anaplastic is very rare.

Question 3

Which of the following features is NOT typical for Graves disease?

A	Hyperplasia of the follicles
B	Scalloping of the colloid
C	Irregular shaped follicles
D	Infiltration of mononuclear cells into retro-orbital connective tissues
E	Extensive infiltration of the mononuclear cells into the thyroid parenchyma

Question 3 Explanation:

Extensive infiltration into the parenchyma is typically seen in Hashimoto's thyroiditis. All other features are typical of Graves disease. In Graves disease IgG TSH-like autoantibodies cause stimulation of the TSH receptor causing hyperplasia of the follicles. These follicles are irregular shape and display scalloping of the colloid.

Question 4

A 37-year-old woman presents to the clinic with 2 days of sudden onset pain in the anterior neck radiating to the jaw. She is otherwise well having reported a full recovery from a ‘cold’ a week ago.

What findings are NOT consistent with her diagnosis?

A	Plasma cells aggregating around damaged thyroid follicles
B	Dense fibrosis of the thyroid gland
C	Neutrophilic infiltration of the thyroid
D	Formation of microabscesses
E	Multinucleated giant cells encapsulating colloid fragments

Question 4 Explanation:

Dense fibrosis of the thyroid gland is usually seen in Riedel's thyroiditis, a rare form of thyroiditis showing fibrosis of the thyroid, neck structures and sometimes other areas of the body. The clinical picture of sudden onset neck pain radiating to the facial region, including the ears, in a 30-50 year old female following a upper respiratory tract infection indicates subacute thyroiditis, also called de Quervain’s thyroiditis.

Question 5

A 62-year-old gentleman presents to the clinic with a 5cm painless neck mass as well as diarrhoea for the past 3 months. A biopsy is taken and he is subsequently diagnosed with medullary carcinoma.

Which of the following features is consistent with a medullary carcinoma?

A	Grossly soft and tender mass
B	Diagnosis of MEN-1 syndrome
C	Haematologic metastatic spread
D	High levels of calcitonin
E	Localised amyloid deposits

Question 5 Explanation:

Malignant cells in an amyloid stroma is a typical feature of medullary carcinoma. It is associated with MEN-2 syndrome, local and lymphatic spread and high levels of calcitonin are seen due the proliferation of parafollicular C-cells (which produce calcitonin). Clinically the mass is usually firm and painless. (Ref: Pathoma, Robbins and Cotran)

Question 6

Which of the following features is NOT consistent with follicular carcinoma?

A	Malignant proliferation of follicular cells
B	Follicular carcinomas are diagnosed via fine needle aspiration
C	More common in women than men
D	Commonly have PI-3K/AKT signalling pathway mutations
E	Uniform cells forming small colloid containing follicles

Question 6 Explanation:

A major differentiating feature between follicular carcinoma and follicular adenoma is the carcinomas ability to break through the follicular capsule. This is unable to be distinguished via fine needle aspiration because the needle breaks through the capsule. All other features are descriptive of follicular carcinoma, with approximately 1/3rd having PI-3K/AKT pathway mutations.

Question 7

A 46-year-old female presents to the preadmission clinic and is found to have a 3cm anterolateral firm painless neck mass along with a minor decrease in calcium serum levels.

What is the most likely diagnosis?

A	Anaplastic carcinoma
B	Medullary carcinoma
C	Follicular carcinoma
D	Papillary carcinoma
E	Parathyroid carcinoma

Question 7 Explanation:

Medullary carcinoma is the proliferation of parafollicular C cells which produce calcitonin. Calcitonin decreases serum calcium, however it should be noted that this is not a prominent feature in medullary carcinoma.

Question 8

Which of the following features are NOT consistent with anaplastic carcinoma?

A	Large, pleomorphic giant cells
B	Occasional osteoclast-like multinucleated giant cells
C	Spindle cells
D	Poor prognosis
E	Positive thyroglobulin markers

Question 8 Explanation:

Anaplastic carcinomas are highly anaplastic, undifferentiated cells and are usually negative for any markers of thyroid differentiation such as thyroglobulin.

Question 9

What thyroid cancer has the worst prognosis? (choose the answer that shows the correct descending order, the first being the cancer with the worst prognosis and the last being the one with the best prognosis)

A	anaplastic > medullary > follicular > papillary
B	anaplastic > medullary > papillary > follicular
C	anaplastic > papillary > medullary > follicular
D	medullary > anaplastic > papillary > follicular
E	medullary > anaplastic > follicular > papillary

Question 9 Explanation:

Anaplastic has a ~20-35% survival at 1 year. Medullary 50% at 10 years. Follicular 92% at 10 years. Papillary 98% at 10 years.

Question 10

An 18-year-old female presents with a painless 1cm mass in the anterior neck region. A biopsy is taken revealing fluid contained within pseudostratified columnar epithelium.

What is the most likely diagnosis?

A	Follicular adenoma
B	Branchial cyst
C	Thyroglossal duct cyst
D	Thyroid cystitis
E	Parotid tumour

Question 10 Explanation:

Thyroglossal ducts are cystic dilations of thyroid duct remnant. The thyroid gland embryologically develops at the base of the tongue and then migrates to the anterior neck, a thyroglossal duct cyst may develop at any stage if the duct fails to close.

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